Quality of Vision After Femtosecond Laser-Assisted Descemet Stripping Endothelial Keratoplasty and Penetrating Keratoplasty: A Randomized, Multicenter Clinical Trial

doi:10.1016/j.ajo.2011.03.012

American Journal of Ophthalmology

Volume 152, Issue 4, October 2011, Pages 556-566.e1

https://doi.org/10.1016/j.ajo.2011.03.012 Get rights and content

Purpose

To compare the quality of vision (straylight and contrast sensitivity) after femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS DSEK) and penetrating keratoplasty (PK).

Design

Prospective, randomized clinical trial.

Methods

setting: Multicenter (5 ophthalmic centers in The Netherlands). study population: Eighty eyes of 80 patients with corneal endothelial dysfunction were included and were randomized to FS DSEK or PK. observation procedures: FS DSEK and PK. main outcome measures: Straylight, contrast sensitivity, astigmatism, uncorrected visual acuity, best spectacle-corrected visual acuity (BSCVA), and visual symptom score.

Results

Straylight at 12 months was 1.37 ± 0.2 logarithm of straylight for FS DSEK and 1.46 ± 0.2 logarithm of straylight for PK (P = .151). During 12 months of follow-up, there was a significant improvement of straylight and contrast sensitivity after FS DSEK (P < .001) and PK (P < .001). The change of straylight and contrast sensitivity correlated significantly with the change of BSCVA after FS DSEK (r = −0.645; r = 0.580) and PK (r = −0.370; r = 0.659). The visual symptom score was comparable between the 2 groups during the 12 months of follow-up.

Conclusions

Improvement of straylight and contrast sensitivity was significantly correlated with an improvement of BSCVA. Straylight and contrast sensitivity were improved significantly after FS DSEK and were comparable with those after PK, although BSCVA was slightly better in the PK group.

Section snippets

Methods

This randomized, multicenter trial was conducted at 5 ophthalmic centers in The Netherlands. Inclusion criteria were endothelial dysfunction caused by Fuchs endothelial dystrophy, aphakic or pseudophakic bullous keratopathy or posterior polymorphous dystrophy, a minimal age of 18 years, and a best spectacle-corrected visual acuity (BSCVA) lower than 20/50. Patients were excluded if they had undergone previous PK, had human leukocyte antigen typed keratoplasty, or were mentally retarded. The

Participant Flow Chart

Eighty eyes of 80 patients were recruited, with 40 eyes in each arm (Figure 1). In the FS DSEK group, 4 patients did not receive the allocated treatment because of significant preoperative events (such as keratitis, corneal ulcers, or both) and eventually were excluded from the study analysis. All patients in the PK group received the allocated treatment.

In the FS DSEK group, 29 eyes were available for analysis at the 12-month follow-up. After surgery, the cornea of 3 eyes remained edematous

Discussion

The purpose of this randomized, multicenter trial was to evaluate the quality of vision (intraocular straylight and contrast sensitivity) and to correlate these quality-of-vision parameters to the refractive and visual outcomes after FS DSEK and PK. Previous studies reported limited visual outcomes after lamellar keratoplasty because of an interface haze, which may increase straylight.13, 27 The main conclusion of our study is that both FS DSEK and PK are very effective at improving straylight,

Yanny Y.Y. Cheng, MD, completed her medical degree from the School of Medicine at Erasmus MC University, The Netherlands. She started working as research fellow in 2005, and began her residency in ophthalmology in 2008 at the Department of Ophthalmology, Maastricht University Medical Centre, The Netherlands. Her primary research interest is the clinical outcomes of lamellar keratoplasty versus penetrating keratoplasty.

References (34)

N.G. Tahzib et al.
Three-year follow-up analysis of Artisan toric lens implantation for correction of postkeratoplasty ametropia in phakic and pseudophakic eyes
Ophthalmology
(2006)
C.W. Tillett
Posterior lamellar keratoplasty
Am J Ophthalmol
(1956)
Y.Y. Cheng et al.
Femtosecond-laser-assisted Descemet's stripping endothelial keratoplasty
J Cataract Refract Surg
(2007)
F.W. Price et al.
Descemet's stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence
J Cataract Refract Surg
(2006)
S.V. Patel et al.
Scattered light and visual function in a randomized trial of deep lamellar endothelial keratoplasty and penetrating keratoplasty
Am J Ophthalmol
(2008)
D.C. Musch et al.
Assessment of health-related quality of life after corneal transplantation
Am J Ophthalmol
(1997)
K.A. Williams et al.
Long-term outcome after corneal transplantationVisual result and patient perception of success
Ophthalmology
(1991)
F.L. Ferris et al.
New visual acuity charts for clinical research
Am J Ophthalmol
(1982)
H. Boisjoly et al.
The VF-14 index of functional visual impairment in candidates for a corneal graft
Am J Ophthalmol
(1999)
H.K. Soong et al.
Femtosecond laser-assisted posterior lamellar keratoplasty: initial studies of surgical technique in eye bank eyes
Ophthalmology
(2005)

M. Mantyjarvi et al.

Normal values for the Pelli-Robson contrast sensitivity test

J Cataract Refract Surg

(2001)

J. Shimazaki et al.

Randomized clinical trial of deep lamellar keratoplasty vs penetrating keratoplasty

Am J Ophthalmol

(2002)

I. Bahar et al.

Comparison of posterior lamellar keratoplasty techniques to penetrating keratoplasty

Ophthalmology

(2008)

H.B. Hindman et al.

Evaluation of deep lamellar endothelial keratoplasty surgery using scatterometry and wavefront analyses

Ophthalmology

(2007)

K.A. Williams et al.

How successful is corneal transplantation?A report from the Australian Corneal Graft Register

Eye (Lond)

(1995)

K.A. Williams et al.

How effective is penetrating corneal transplantation?Factors influencing long-term outcome in multivariate analysis

Transplantation

(2006)

M.S. Gorovoy

Descemet-stripping automated endothelial keratoplasty

Cornea

(2006)

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Femtosecond Lasers in Cornea & Refractive Surgery
2021, Experimental Eye Research
Since the introduction of femtosecond laser (FS) systems for corneal flap creation in laser-assisted in-situ keratomileusis there have been numerous applications for FS laser in corneal surgery. This manuscript details the utility of FS lasers in corneal surgical procedures including refractive laser surgeries, intracorneal ring segment tunnels, presbyopic treatments, and FS-assisted keratoplasty. We also review the role of FS lasers in diagnostic procedures such as two photon excitation fluorescence and second harmonic generation.
Clinical features and visual function in a patient with Fish-eye disease: Quantitative measurements and optical coherence tomography
2018, American Journal of Ophthalmology Case Reports
Citation Excerpt :
The effect of deep lamellar endothelial keratoplasty and penetrating keratoplasty on straylight values was small.25 Both Descemet stripping endothelial keratoplasty and penetrating keratoplasty for Fuchs' endothelial corneal dystrophy improved stralylight postoperatively,26–29 while another study showed greater straylight values after Descemet stripping endothelial keratoplasty compared to penetrating keratoplasty.30 In the present case, because there were no other abnormal eye findings, it was assumed that the remarkably increased straylight was due to the massive diffuse corneal clouding.
We describe a case of fish-eye disease (FED) where the clinical features and visual function were investigated using anterior segment optical coherence tomography (OCT) and quantitative measurements.
A 36-year-old Japanese woman with FED presented with bilateral corneal opacities and visual complaints. Both contrast sensitivity and straylight were measured and OCT imaging was performed. Contrast sensitivity and straylight measurements revealed remarkably decreased visual function, despite good visual acuity. OCT demonstrated homogenously hyper-reflective corneal opacification, and a normal total corneal thickness.
The findings from this case suggest that OCT is useful for analyzing the clinical features of FED, and that the quantitative measurement of visual function furthers the understanding of vision-related symptoms in FED, despite good visual acuity.
Changing Practice Patterns and Long-term Outcomes of Endothelial Versus Penetrating Keratoplasty: A Prospective Dutch Registry Study
2016, American Journal of Ophthalmology
Citation Excerpt :
Compared with PK, visual recovery following EK is reported to be faster.1–15 However, the extent of visual recovery following EK is suggested to be limited owing to anterior corneal scarring and a donor-recipient interface.9,18,24–27 Our real-world results indicate that, correcting for baseline differences in visual acuity, visual recovery following EK for the treatment of FED and PBK is faster and better compared with PK, especially during early postoperative follow-up.
To compare graft survival, best-corrected visual acuity (BCVA), endothelial cell density (ECD), and refraction following penetrating keratoplasty (PK) vs endothelial keratoplasty (EK) for Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK).
Nonrandomized treatment comparison with national registry data.
All consecutive patients undergoing first keratoplasty for FED and PBK between 1998 and 2014 were analyzed, with a maximum follow-up of 5 years (mean ± SD follow-up 39 ± 20 months, range 0–60 months). Graft survival was analyzed using Kaplan-Meier survival curves and Cox regression analysis. BCVA, ECD, and refractive error were compared using linear mixed models. Main outcome measures were graft survival, BCVA, refraction, and ECD.
A total of 5115 keratoplasties (PK = 2390; EK = 2725) were identified. Two-year graft survival following EK was lower compared with PK (94.5% vs 96.3%, HR = 1.56, P = .001). Five-year survival was comparable for EK and PK (93.4% vs 89.7%, HR = 0.89, P = .261). EK graft survival improved significantly over time while remaining stable for PK. One-year BCVA was better following EK vs PK (0.34 vs 0.47 logMAR, P < .001). Astigmatism was lower 1 year after EK vs PK (−1.69 vs −3.52 D, P < .001). One-year ECD was lower after EK vs PK (1472 vs 1859 cells/mm², P < .001). At 3 years, ECD did not differ between EK and PK.
Long-term graft survival after EK and PK is high and comparable despite lower short-term survival for EK. EK graft survival improved over time, suggesting a learning curve. EK results in better BCVA, lower astigmatism, and similar long-term ECD compared with PK for FED and PBK.
Excimer laser-assisted lamellar endothelial keratoplasty (ExALEK): Technique and results
2016, Journal Francais d'Ophtalmologie
Le but de cette étude est de décrire une technique de préparation de greffons lamellaires endothéliaux fins et d’en exposer les résultats pour greffe endothéliale réalisée au CHU de Nantes.
Il s’agit d’une étude descriptive rétrospective et monocentrique réalisée au CHU de Nantes de septembre 2010 à mai 2014 tout d’abord dans des indications anatomiques ou antalgiques (groupe 1) puis étendue aux indications visuelles (groupe 2). Les patients étaient suivis sur 12 mois. La technique originale de préparation du greffon endothélial comporte une photoablation au laser Excimer du lit stromal résiduel après kératectomie lamellaire par voie antérieure profonde manuelle.
Soixante-dix interventions ont été analysées. Les étiologies étaient pour la majorité la dystrophie endothéliale primitive de Fuchs, la dystrophie endothéliale secondaire et la défaillance endothéliale de greffe transfixiante. Cinquante-trois patients ont été inclus dans le groupe 1 et 17 patients dans le groupe 2. Dans le groupe 1, l’AV moyenne à 12 mois était de 0,70 ± 0,30 LogMAR (0,2 équivalent décimale). Dans le groupe 2, l’AV moyenne à 12 mois était de 0,28 ± 0,12 LogMAR (0,5 équivalent décimale). La pachymétrie passait de 740 ± 125,1 μm en préopératoire à 613,4 ± 73,4 μm à 12 mois. L’épaisseur centrale moyenne du greffon était de 84,1 ± 28,9 μm à 1 mois et de 80,2 ± 29,4 μm à 12 mois.
Cette technique présente l’avantage d’être une méthode rapide et reproductible permettant de produire des greffons fins avec une fonctionnalité satisfaisante et de manipulation aisée. Sa réalisation en amont et indépendamment de la chirurgie programmée permet une organisation prédictible au bloc opératoire.
The purpose of this study is to describe a technique for thin endothelial lamellar keratoplasty and to present the results for endothelial transplant performed at the University Hospital of Nantes.
This paper is a retrospective, single-center descriptive study conducted at the University Hospital of Nantes from September 2010 to May 2014, at first for anatomical or analgesic indications (group 1) and then extended to visual indications (group 2). Patients were followed for 12 months. The preparation of the endothelial graft includes an excimer-laser ablation of the residual stromal bed after lamellar keratectomy by manual deep anterior approach.
Seventy surgeries were analyzed. The etiologies were mainly Fuchs Dystrophy, secondary endothelial dystrophy and post-penetrating keratoplasty endothelial failure. Fifty-three patients were integrated in group 1 and seventeen patients in group 2. In group 1, the mean VA at 12 months was 0.70 ± 0.30 LogMAR (0.2 decimal equivalent). In group 2, the mean VA at 12 months was 0.28 ± 0.12 LogMAR (0.5 decimal equivalent). Pachymetry decreased from 740 ± 125.1 μm preoperatively to 613.4 ± 73.4 μm at 12 months. The average central thickness of the graft was 84.1 ± 28.9 μm at 1 month and 80.2 ± 29.4 μm at 12 months.
The advantage of this new surgical technique is that it is a rapid and repeatable method allowing thin grafts with satisfactory functionality and easy handling. Its performance independent of the scheduled surgery, allows for predictable organization in the operating room.
Femtosecond and excimer laser-assisted endothelial keratoplasty (FELEK): A new technique of endothelial transplantation
2014, Journal Francais d'Ophtalmologie
To describe a new technique of endothelial keratoplasty (EK) that improves the quality of lamellar dissection of donor cornea.
We compared four techniques of donor cornea preparation for lamellar dissection on 8 donor corneas: mechanical dissection with a microkeratome, a single femtosecond laser lamellar cut, a double femtosecond laser lamellar cut and combined femtosecond laser lamellar dissection with excimer laser surface photoablation. The quality of the donor cornea interface was assessed and compared using scanning electron microscopy (SEM), and the most satisfactory technique was employed for EK on three patients. The postoperative anatomic results were analyzed with anterior segment spectral-domain optical coherence tomography (SD-OCT) and in vivo confocal microscopy (IVCM).
The smoothest stromal interface was observed on SEM with the combined use of femtosecond laser dissection and excimer photoablation. The surgical procedures performed with donor cornea prepared by a combination of femtosecond and excimer lasers resulted in clear corneas after 1 month. SD-OCT showed good attachment of the endothelial graft and a hyperreflective interface. On IVCM, subepithelial haze, honeycomb-like activated keratocytes and needle-shaped particles were visible in the recipient corneal stroma as well as numerous hyperreflective particles on the donor–recipient interface.
A new technique, femtosecond and excimer laser-assisted endothelial keratoplasty (FELEK), which refines the current limitations observed in Descemet-stripping automated endothelial keratoplasty (DSAEK), is described. Femtosecond laser dissection provides a thin and reproducible endothelial graft cut with a high level of safety and accuracy, while excimer photoablation yields a smooth, high-quality interface.
Décrire une nouvelle technique de kératoplastie endothéliale améliorant la qualité de découpe du greffon cornéen.
Nous avons comparé 4 techniques de découpe pour la préparation du greffon sur 8 greffons : une découpe mécanique au microkératome, une découpe unique au laser femtoseconde, une double découpe au laser femtoseconde et une découpe au laser femtoseconde combinée à une photoablation de surface au laser excimer. La qualité de l’interface des greffons a été analysée en microscopie électronique et la technique la plus satisfaisante a été appliquée pour réaliser une greffe endothéliale sur 3 patients. Les résultats anatomiques post-opératoires ont été analysés en OCT spectral-domain (OCT-SD) de segment antérieur et en microscopie confocale.
L’interface stromale la plus lisse a été observée avec la combinaison du laser femtoseconde et du laser excimer. La procédure chirurgicale réalisée avec cette technique a abouti à des cornées claires à 1 mois. L’OCT-SD a montré un greffon endothélial bien appliqué ainsi qu’une interface hyper-réflective. En microscopie confocale, un haze sous-épithélial, et des kératocytes activés étaient visibles dans le stroma ainsi que de nombreuses particules hyper-réflectives dans l’interface.
La kératoplastie endothéliale assistée aux lasers femtoseconde et excimer (FELEK) a été décrite. La découpe au laser femtoseconde permet d’obtenir un greffon cornéen fin et reproductible avec plus de sécurité et de précision tandis que la photoablation de surface au laser excimer donne une interface lisse et de bonne qualité.
History of ocular straylight measurement: A review
2013, Zeitschrift fur Medizinische Physik
Citation Excerpt :
Other studies investigating straylight outcome after DSEK and PK for Fuch's dystrophy showed a significant improvement [169–171], also for long term follow-up [172]. Whereas Cheng et al. showed comparable outcome after PK and DSEK regarding straylight [169], another study showed straylight values to be higher after DSEK than after PK [173]. Keratoconus patients can show increased straylight values which could not be explained by age or scarring and is supposedly related to structural degradation of the cornea [86].
The earliest studies on ‘disability glare’ date from the early 20^th century. The condition was defined as the negative effect on visual function of a bright light located at some distance in the visual field. It was found that for larger angles (>1degree) the functional effect corresponded precisely to the effect of a light with a luminosity equal to that of the light that is perceived spreading around such a bright source. This perceived spreading of light was called straylight and by international standard disability glare was defined as identical to straylight. The phenomenon was recognized in the ophthalmological community as an important aspect of the quality of vision and attempts were made to design instruments to measure it. This must not be confused with instruments that assess light spreading over small distances (<1 degree), as originating from (higher order) aberrations and defocus. In recent years a new instrument has gained acceptance (C-Quant) for objective and controllable assessment of straylight in the clinical setting. This overview provides a sketch of the historical development of straylight measurement, as well as the results of studies on the origins of straylight (or disability glare) in the normal eye, and on findings on cataract (surgery) and corneal conditions.
Am Anfang des 20. Jahrhunderts wurden umfangreiche Untersuchungen zur „physiologischen Blendung“ durchgeführt, definiert als die Beeinträchtigung des Sehens durch eine helle Lichtquelle, die in einem bestimmten Abstand innerhalb des Gesichtsfelds gelegen ist. Es wurde herausgefunden, dass für größere Winkel (>1Grad) der Funktionseffekt genau dem Effekt eines Lichtes mit einer Helligkeit entsprach, die der des Lichtes gleich ist, das als um eine solche helle Quelle herum sich ausbreitend wahrgenommen wird. Dieses um eine Lichtquelle herum wahrgenommene Licht wurde Streulicht genannt und als internationaler Standard wurde die physiologische Blendung als identisch zum Streulicht definiert. Das Phänomen wurde in der ophthalmologischen Gemeinschaft als wichtiger Aspekt der Qualität des Sehens erkannt und es wurde versucht, Instrumente zu entwerfen, um sie zu messen. Die Instrumente zur Streulichtmessung dürfen nicht mit solchen Instrumenten verwechselt werden, die sich in kleinem Winkel (<1 Grad) ausbreitendes Licht messen, welches durch Aberrationen (höherer Ordnung) und Defokussierung entsteht. Seit einigen Jahren gibt es ein Instrument (C-Quant) zur objektiven und kontrollierbaren Bestimmung von okularem Streulicht in der Klinik. In diesem Überblick werden die historische Entwicklung der Messung des okularen Streulichts, der Untersuchungen zum Ursprung von Streulicht (oder physiologischer Blendung) im normalen Auge sowie die Ergebnisse für Katarakte (Chirurgie) und Korneakonditionen skizziert.

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Original articleQuality of Vision After Femtosecond Laser-Assisted Descemet Stripping Endothelial Keratoplasty and Penetrating Keratoplasty: A Randomized, Multicenter Clinical Trial

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Participant Flow Chart

Discussion

Ophthalmology

Am J Ophthalmol

J Cataract Refract Surg

J Cataract Refract Surg

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

J Cataract Refract Surg

Am J Ophthalmol

Ophthalmology

Ophthalmology

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Eye (Lond)

How effective is penetrating corneal transplantation?Factors influencing long-term outcome in multivariate analysis

Transplantation

Descemet-stripping automated endothelial keratoplasty

Cornea

Original article
Quality of Vision After Femtosecond Laser-Assisted Descemet Stripping Endothelial Keratoplasty and Penetrating Keratoplasty: A Randomized, Multicenter Clinical Trial